APPLICATION OF NURSING THEORY 2 Nursing theory remains the cornerstone of the nursing profession. Now more than ever nursing knowledge is rapidly undergoing refinement. As the healthcare world continues to transform, nursing professionals are progressively restructuring nursing theory. Nursing theory can be applied as a guide to help restructure and solve nursing practice issues by facilitating reflection, questioning and critical thinking about the effectiveness of what nurses do. Application of theory by nurse leaders and nurse educators can influence outcomes of patient satisfaction scores, patient-care delivery, and workflow design. The grand theory by Betty Neuman can be applied to this challenge. The Betty Neuman’s system model considers a client system (individual, group, or community) working with a nurse to identify stressors, defenses, and adaptations. The Neuman model has identified variables which can interact with the client system (staff nurses) to alter their perception of stressors. These variables are physiological, psychological, sociocultural, developmental, and spiritual (Ume-Nwagbo, DeWan, &Lowry, 2006). Together, the nurse and client system assess actual and potential effects of the environmental stressors and assists the client system with either reducing the risk of the stressor, strengthening the defense lines of resistance, treating the effects, adapting, re-adapting, and/or preventing future occurrences of the stressor (Florczak, K., Poradzisz, M., Hampson, S., 2012). The goal is to maintain stability. The process is dynamic and on-going. Potential outcomes of the Neuman systems model can be detrimental or beneficial. The purpose of this paper is to explain the concepts of the Neuman systems model to provide a better understanding of the theory’s applicability to
A theory is a set of statements proposed to explain a given circumstance or phenomenon (Peterson & Bredow, 2009). Theory is not necessarily upheld as factual or universal truth. However, the extent of its influence may reach so widely that everyone uphold and use a certain theory in guiding practice. In nursing, theories are very important because these serve as a foundation from which practice of the profession can better be understood. Theory allows nursing practitioners and scholars to be open to possibilities of greater knowledge base and understanding of how the profession is developed.
In this paper, different nursing theories will be discussed, compared, and contrasted. Further understanding of the chosen theories will be delved upon by reviewing the background of its theorists in relation to the formed theoretical framework. Furthermore, a discussion on the different concepts (nursing, environment, health, and person) encompassed in the theory will be included. Research studies that were guided by these theories will also be reviewed and appraised.
Nursing Research and Theories
Nursing research is a process of identifying evidences to support the practice of nursing. Today, the nursing practice is moving toward evidence-based approach, which helps increase professional credibility and authority in the field. Through nursing research, the different assumptions and theories that guide nursing practice are identified. These become the framework from which nursing researches proceed (Kozier, Erb, Berman, & Snyder, 2004).
In some ways, nursing research provide avenues to test foundational nursing theories that have been widely accepted for years. Through research, new evidences are explored in giving support to present nursing theories, as well as providing more understanding regarding the theories and assumptions that outline nursing practice. In a sense, it provides a stronger foundation through which nursing theories are built.
Furthermore, nursing research may also result in the development of new theories based on past theories. Through this, gaps in the existing literature of nursing theories may be identified. Loopholes in the assumptions can be recognized and addressed by expounding from existing theories and developing newer ones. These help in furthering the knowledge base that could enhance nursing practice and education.
It should be noted that nursing researches give birth to new nursing theories and conversely, nursing theories pave the way for coursing action of nursing research. Note that there is an abundance of nursing theories and these theories do not tackle a single path or theme. The abundance in number also varies in ideas or perspectives. This diversity leads to several clinical inquiries that guide the development of research questions. Because nursing theorists differ in perspectives or view of concepts, we are allowed to inquire and interpret differently. These inquiries and questions lead to nursing researches that pave the way for development of new ideas.
Grand and Midlevel Theories
Though grand theories occasionally guide nursing research, midlevel (middle range) theories are more commonly used in the development of nursing researches. Midlevel theories give emphasis on more specific concepts of physiological, cognitive, social, and emotional aspects of humans (Kozier et al., 2004). On the other hand, grand theories tackle broad assumptions about abstract relationships among concepts in a bigger picture (Peterson & Bredow, 2009).
According to Peterson and Bredow (2009), examples of midlevel theories are the following:
- Hardiness (emotional)
- Health belief (cognitive)
- Learned response to chronic illness (cognitive)
- Grief (emotional)
- Chronic pain (physiological)
- Maternal Role Attainment (social)
On the other hand, grand theories include the following (Kozier et al., 2004):
- King’s Goal Attainment theory
- Orem’s General Theory of Nursing
- Roger’s Science of Unitary Human Beings
- Peplau’s Interpersonal Relations Model
- Neuman’s Systems Model
- Parse’s Human Becoming Theory
Comparison of Nursing Theories and Theorists
In this section, three nursing theories will be compared. As a prelude, the different backgrounds of the nursing theorists will be related to their formed theoretical frameworks. This discussion will include the theories of Hildegard Peplau, Betty Neuman, and Dorothea Orem.
Background and Theoretical Framework
Hildegard Peplau (Interpersonal Relations Model).
Hildegard Peplau is a pioneering professional nurse in the field of mental health and psychiatric nursing. She earned her master’s degree in psychiatric nursing from the Colombia University and continued on with her professional practice thereafter. She was one of the strong advocates in uplifting the nursing profession to become a respected field of study and practice toward modern world. Her extensive practice in the field of mental health nursing influenced her to develop the framework for her Interpersonal Relations Model (Peter & Bredow, 2009).
Note that Peplau’s model deals greatly with the nurse-client relationship, which is the key feature of psychiatric nursing. It can be inferred that Peplau’s clinical practice and background in psychiatric nursing influenced her piece of work. Her mastery of the field and belief in the nurse-client relationship helped her develop a model that best represents the system of nurse-client relationship and the nurse’s use of therapeutic self.
Betty Neuman (Systems Model).
Betty Neuman worked as a registered nurse in the psychiatric setting. She completed her MS in Mental Health Public health consultation from the University of California, Los Angeles. She earned a doctorate degree in clinical psychology as well. Neuman initially developed her model in order to provide a course guideline for graduating nursing students under her care. While she was teaching in a community health setting, Neuman developed this model (Peter & Bredow, 2009).
In a sense, the development of this model was influenced by the urge to communicate understanding to students regarding the proper holistic approach of nursing. Note that Neuman’s model views the person as an open system influenced by different factors. Also, within the person, there are innate elements (physiological, psychological, social) that drives the person’s reaction to the environment. Neuman’s background in relation to the theory shows that her understanding of the different processes that affects a human being cannot be viewed in parts but in a holistic view and this is encompassed in her developed systems model.
Dorothea Orem (Self-Care Theory).
Dorothea Orem completed her bachelor’s and master’s degree in nursing at the Catholic University of America. Her nursing experience included a wide expanse of clinical settings, most strikingly serving as a private duty nurse. During Orem’s time, the nursing profession is not highly regarded. Mass media portrays nurses as a lowly class of profession. Hence, this situation of nurses sparked Orem’s aim to uplift the condition and professional credibility of nurses and nursing (Peter & Bredow, 2009).
These backgrounds can be inferred as influencing factors to Orem’s development of her Self-Care Theory. Note that Orem wanted to prove the worth of nurses hence, the nurse’s role and responsibility in being an agent to help people provide care for them became the basis of Orem’s theory. Also, remember that Orem worked as a private duty nurse hence, the image of persons and families as individuals who need help to provide self-care for them when the requirements for self-care exceed what they are capable of underlies the developed theory of Orem.
Definitions and relationships among concepts/elements
Definition of Concepts (Nursing).
In Peplau’s Interpersonal Relations Model, nursing is defined as an important interpersonal process that is therapeutic in nature. Health is achieved and made possible for people through cooperative function with other humans (Kozier et al., 2004). This model assumes that therapeutic communication and education is allowed by the nursing process through the formation of nurse-client relationship. Hence, this model holds that nursing is therapeutic and educative.
Note that emphasis is given on the term interpersonal relations, which gives the notion of reference to people outside the client or patient. However, there is no focus on the relationship with other people, such as family and relatives, aside from the nurse. Hence, this suggests that the main interpersonal relation focused in this model is the relationship between the nurse and the client. In effect, the nurse becomes the major influencing person for the client’s health and wellness. Thus, the nurse assumes different roles to maintain an optimal therapeutic relationship with the client that will result in the alleviation of the patient’s condition.
Neuman’s Systems Model assumes that nursing is basically concerned with the stability of the patient or client against stress and stressors (Kozier et al., 2004). Stability can be achieved through a balance of the different factors. The main goal of nursing is to build the defense of the client as such there are three lines of defense that are circular in nature. The primary, secondary, and tertiary levels of prevention addresses these. The primary level of prevention focuses on strengthening the normal line of defense, which is farther from the client’s core. The secondary level of prevention strengthens the inner lines of defense, which are closer to the client’s core. Last, the third level of prevention focus on readapting and stabilizing the client into former state of wellness (Kozier et al., 2004). In line with these assumptions on the model, nursing action is directed toward maintaining health and wellness for the client using these.
In Orem’s Self Care Theory, nursing is viewed as a helping service. Nursing actions are directed by a deliberate will to help populations within the scope of duty to optimize their health conditions and the surrounding environment (Kozier et al., 2004). In a long-term approach, nursing is rendering care or service to clients in order to help and empower them to meet their needs on their own hence, self-care.
Definition of Concepts (Person).
Peplau’s theory views a person as a system composed of different elements, namely, physiological, psychological, and social aspects. These elements constantly interact with each other as the person interacts dynamically with his surroundings. The person continues to seek equilibrium or balance however, this search is always challenged because true equilibrium only occurs when on dies. As a person lives, he is in a state of instability in a sense that there will always be ups and downs and changing. There is no fixed pattern only until death (Kozier et al., 2004).
In Neuman’s model, the person is viewed as a core being encircled by different lines of defense to protect self from stressors. There are three lines of defense which surrounds the person in different levels or layers. Nearest the core (person) are the multiple lines of resistance. Surrounding these are the normal lines of defense of the person, and the last is the flexible line of defense (Kozier et al., 2004). If one should imagine this, the person is a circle inside the different layers of concentric rings or spheres that represent the lines of defense or resistance.
Neuman’s model sees the person as an open system that continuously interacts with its surrounding environments. The lines of defense aid the person in fighting and maintaining balance within the self. However, within the core of the person, he contains innate characteristics that are both strong and weak, which comprise the system of the person as a whole. These innate characteristics drive the client in regaining harmony and balance with his self and environment.
In Orem’s theory, a person is viewed as someone whose capabilities for self-care are limited (Kozier et al., 2004). Because of this, the person is not able to effectively and holistically care for himself. Thus, nursing deals with helping the person gain self-care skills to maintain optimum health and wellness.
Definition of Concepts (Health).
In Peplau’s model, health is achieved through dynamic and therapeutic interaction between client and self, and client and other people (Kozier et al., 2004). This means that in order for one to be considered healthy, the person’s physiological needs should be met. This fulfills the client’s interaction with self. Furthermore, the client should be able to form healthy interpersonal relations in order to meet one’s personal and social needs. These allow the person to healthily express himself and these allow for a productive show of one’s thoughts, feelings, wants, and needs.
In Neuman’s model, health is viewed as an illness-wellness continuum. This means that the client’s degree of stability can be plotted in the continuum of health and that the most stable condition is judged as the highest possible state of wellness. Furthermore, Neuman believes that health is a manifestation of the live energy released from the human system as the person is viewed as an open system (Kozier et al., 2004). In this context, health is viewed as a resulting form of live energy as the client interacts with the environment. As the client’s lines or spheres of defenses are invaded by stressors from the environment, health is also varied as nearing either illness or wellness.
In Orem’s theory, the terms health and healthy are viewed as a desciption of living things such as human beings (Kozier et al., 2004). Health or the state of being healthy is described for living things that display a state of wholeness in function and structure. This means that a health is seen as a state of holistic wellness which includes physiological, psychological, emotional, social, and spiritual wellness.
Definition of Concepts (Environment).
In Peplau’s model, the environment is viewed as an element that occurs within the context of the relationship between the nurse and the client (Kozier et al., 2004). This means that the environment is a product or creation of the interacting relationship between the client and nurse. Take note that the focus is also given on the formed relationship and not the individuals per se. Therefore, the environment is not a fixed structure that influences the relationship of the individuals, rather it is ongoing and concurrent with the process and relationship formed between nurse and client. This view of the environment can be seen as very different from the two other views of the environment in their theories and models.
In Neuman’s model, the environment is a summary of all internal and external elements that influence the client (Kozier et al., 2004). These are the forces that challenge the lines of resistance of the client. These are also called the stressors, which can affect the client in either a positive or negative way. The stressors, by themselves, can also be positive or negative in nature.
The environment that is in constant interaction with the individual can either be internal, external, or created. The internal environment is within the client’s system. On the other hand, the external environment is outside the client’s system. Meanwhile, the created environment is a product of the client’s ability to manipulate the elements within his system that encompasses both internal and external environments. The interaction between the client and the environment is a process of reacting to the presenting stressors to the client that could lead to correction of change or regulation and maintenance of the balance within the client’s system.
In Orem’s theory, environment is simply viewed as the surrounding elements around the person (Kozier et al., 2004). These can be stressors, environmental factors, existing phenomenon, and conditions that could affect the person.
Research studies have been directed by nursing theories in this profession. In this section, examples of research studies that have used the discussed nursing theories earlier will be cited. First, Peplau’s Interpersonal Relations Theory often guides researches on populations with mental health problems and psychiatric disorders. In one research study, Peplau’s theory is used as a guide in order to describe the process of recovery in depressed women. The research included seven women who were previously hospitalized and diagnosed with depression. Peplau’s theory guided the descriptive study in explaining the recovery phases of depressed women (Peden, 1993).
Second, Betty Neuman’s theory often guides researches that tackle topics on stressors and illnesses. Hence, population groups mostly included in these researches are sick people and caregivers of sick people who are at high risk for caregiver role strain. As proof of this, in a systematic review conducted by Skalski, DiGerolamo, and Gigliotti, five types of populations or clients were identified as populations who were frequently included in researches conducted on stressors. These include givers and receivers of care, survivors of cancer, patients in the intensive care units, and parents of children scheduled for surgery (Skalski et al., 2006). Researches formed around Neuman’s theoretical framework usually involves research questions on the empirical evidence or basis of stress and levels of strain in different levels and types of clients.
Last, Orem’s theory often guides researches on populations that are at a high-risk for self-care deficit. These include people who are obese or part of the aging population or the elderly ages 65 and above. Another population group who also have self-care deficit needs are the pediatric population. This population has also been used in researching the effectiveness of Orem’s self-care theory as a theory-based nursing care approach (Haas, 1990). Another vulnerable population in the field of nursing research that used Orem’s self-care theory is among burn patients. Burn patients are among the people with unique basic care needs. In one recent research study, the research asked the effectiveness of Orem’s theory in application to theory-based nursing care in comparison to other theories. Using Orem’s theory in directing a theory-based nursing care approach was concluded to be an effective approach for care in these patients (Wilson & Gramling, 2009).
Selected Nursing Theory
The nursing theory that is best congruent with my beliefs is Peplau’s Interpersonal Relations Model that describes the nurse-client relationship. As discussed, Peplau’s theory assumes that health and wellness can be best achieved through an effective and therapeutic relationship between the nurse and client. In my case, I believe that the nurse-client relationship is very important in the client’s health. Similarly, I also believe in the power of interpersonal relations through the four phases of interaction.
Peplau’s theory has guided me in my nursing practice, especially in psychiatric nursing. This theory is easily embedded in the nursing process, which is the core of the nursing profession. Note that Peplau views nursing as both educative and therapeutic. It is through this concept that both the client and nurse find and develop ways to provide solutions for the client’s problems. Similarly, this is the process through which I establish my relationship with my clients toward building a trusting relationship that helps in resolving my clients’ problems.
For example, I had a client admitted in the psychiatric unit who was already admitted before. Hence, establishing the rapport and relationship with the client is easy. Next, my client and I both moved on to the next phase of identifying his needs and problems. In this phase, we were able to identify the client’s feelings of guilt and sadness toward the death of his mother. We were also able to recognize the presence of hallucinations (auditory) in the client. After identifying these problems, we moved on to the exploitation phase in which we utilized all available resources to help the client resolve his needs. One-on-one interaction has been best for the client since I have gained the trust of the client. Support groups were also identified to help the client. By the time we reach the resolution phase, the client has become more empowered on how to deal with his problems effectively.
Using Peplau’s model, I was able to establish a beginning relationship with the client. Through identification of the client’s problems, the client began to put more trust in me. This allowed me and the client to use effectively the resources that are available to help him. In the end, the client was empowered to help himself. Indeed, Peplau’s emphasis that the nurse-client relationship in nursing is both educative and therapeutic.
- Haas, D. L. (1990). ‘Application of Orem’s self-care deficit theory to the pediatric chronically ill population.’ Issues in Comprehensive Pediatric Nursing, 13(4), 253-264. doi: 10.3109/01460869009014488
- Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Singapore: Pearson Education, Inc.
- Peden, A. R. (1993). ‘Recovering in depressed women: research with Peplau’s theory.’ Nursing Science Quarterly, 6(3), 140-146. Retrieved August 7, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/8361713
- Peterson, S. J & Bredow, T. S. (2009). Middle-range theories: Application to nursing research (2nd ed.). Retrieved August 5, 2010, from http://books.google.com.ph/books?id=AM-xy5LRzMsC&printsec=frontcover#v=onepage&q&f=false.
- Skalski, C. A., DiGerolamo L., & Gigliotti, E. (2006). ‘Stressor in five client populations: Neuman systems model-based literature review.’ Journal of Advanced Nursing, 56(1), 69-78. Retrieved August 7, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/16972920.
- Wilson, J. & Gramling, L. (2009). ‘The application of Orem’s self-care model to burn care.’ Journal of Burn Care and Research, 30(5), 852-858. Retrieved August 7, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/19692925.
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